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A Closer Look at How to Manage Heart Failure

CardioSmart News

By David I. Feldman, MD, MPH; Kim Cuomo, CRNP; Roger S. Blumenthal, MD; Roberta Florido, MD, MHS

The American College of Cardiology and the American Heart Association updated the guideline for managing heart failure in 2017. Here are key points that all patients with heart failure should know about healthy lifestyle and proven medications, new heart failure medications, patient self-monitoring, physical activity, and the impact of diabetes.

Healthy Lifestyle & Proven Medications

In patients with a history of heart failure, implementing evidence-based dietary and medication changes helps promote recovery and prevent disease progression.

The first step in controlling cardiovascular disease risk factors (including high blood pressure, cholesterol, obesity, and diabetes mellitus) is following a heart-healthy diet, increasing daily physical activity levels, reducing sedentary behavior, and avoiding tobacco products. These changes include replacing most saturated fats, red meat, and processed foods in the diet with fruits and vegetables, lean protein, whole grains, and healthy oils. Restricting sodium intake to fewer than 2,000 mg per day and limiting fluid intake to fewer than 64 ounces a day may also help reduce the risk for heart failure symptoms.

The cornerstone of managing heart failure is guideline-directed medical therapy, which is proven to reduce symptoms, repeat hospitalizations, and deaths. Nearly all patients with coronary artery disease and signs or symptoms of heart failure should be started on the following:

  • An angiotensin converting enzyme-inhibitor (ACE-I) or angiotensin receptor blocker (ARB): These medicines help relax blood vessels to lower blood pressure and reduce strain on the heart.
  • A beta-blocker: This medicine can slow a rapid heart, lower blood pressure and reduce strain on the heart.
  • A statin (if the LDL cholesterol is at least 70 mg/dL): This medicine helps lower LDL cholesterol levels.

Medication doses will be optimized over time. This usually involves increasing the dosage of the medication to the maximal level tolerated by patients. By helping to lower blood pressure, cholesterol and stress on the heart, these medications will promote healing and improve heart function. Often, making these dietary and medication changes will improve heart failure signs and symptoms.

If the patient continues to have symptoms of heart failure (such as shortness of breath with moderate walking or climbing stairs) despite following the medical therapy as outlined above, other treatment options exist and should be discussed with the cardiovascular specialist.

Consideration can be given to adding a mineralocorticoid receptor antagonist (MRA) such as spironolactone to address fluid retention, changing the ACE-I or ARB to an angiotensin receptor blocker/neprilysin inhibitor (ARNI) or both. An MRA or ARNI are often considered for all patients with at least moderate impaired heart muscle function (Ejection Fraction <40%) even if they do not have complaints of shortness of breath with exercise.

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